APPENDICITIS

History 1800 terms typhlitis and paratyphlitits used for RLQ inflammation started to appear 1827 Meiler described appendicitis on autopsy and proposed correct pathophysiology, but was opposed by Dupuyitren 1880 - Matterstock in Germany and With in Norway published papers that clearly point to the appendix as a significant cause of iliac fossa inflammation. 1886 - Reginald Fitz of Boston coined the term appendicitis and recommended early surgical treatment of the disease 1889 - Chester McBurney described the migratory pain as well as RLQ point tenderness o McBurney described muscle splitting incision 1905 Murphy described the appropriate sequence of symptoms 1940s Penicillins availability mortality less than 2%

Incidence max late teens and 20s, M>F slightly, infrequent in extreme ages Pathophysiology: luminal obstruction (lymph/fecalith/other) - intraluminal pressure/overgrowth/necrosis perforationabscess/peritonitis Bacteriology is highly predictable colonic flora. If there is no perforation less than 50% positive peritoneal cultures, with perforation 85% positive. Usefulness of initial cultures is very questionable. Diagnosis primarily is clinical, depends on stage of the disease and localization of the appendix, classical < 50%. Imaging: CT (90% sensitivity, 80-90% positive predictive value), true sensitivity is unknown, depends on inclusion criteria, with the stage U/S experienced radiologist needed, depends on institution policy Abdominal radiographs usually non-specific, barium enema now not used routinely Nuclear imaging true value is unknown Laboratory mild leucocytosis, left shift; U/A mild pyuria Differential depends on age, sex, presentation: AGE, Diverticulitis, Mesenteric lymphadenitis, Meckels diverticulitis, intussusception, Crohns disease, perforated

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peptic ulcer, perforated cecal/sigmoid Ca, UTI, Renal colic, GYN disease, acute scrotum, torsion of appendix epiploica, SBP, HSP, Yersiniosis. Treatment depends on presentation/stage of the disease, see suggested protocol Appendectomy(Lap/open) immediately, unless there is periappendicular phlegmon or abscess are present (IV Abx course, drainage of abscess(CT-guided), interval appendectomy) Special circumstances: infants, elderly patients, pregnant. Laparoscopy benefit for female, obese patients or when diagnosis is unclear. Perforated Appendicitis course of post-op Abx for 7-10 days and norm WBC and T norm Postoperative Complications o Infection most common complication(wound <5%/abd.cavity<1% for nonperforated appendicitis) o Wound usually safe (cost-effective) to close even for complicated disease o ? Increased rate of post-op abscess formation after laparoscopic appendectomy o Other post-op complications: bowel obstruction, infertility, miscellaneous (UTI, pneumonia, fecal fistula) Sergey Khaitov, M.D.

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